Gracy Woods II Living Center

In the surveyor’s words

From the most serious findings on record at Gracy Woods II Living Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 28, 2021

  Based on observation, interview, and record review, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one of three residents (Residents #1) reviewed for pressure ulcers. […]

• No harm, potential for more than minimal, widespreadF812Aug 19, 2021

  Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 82 of 82 residents who consumed food from 1 of 1 kitchen; in that: 1) The facility failed to ensure foods were protected from possible contamination during processing and storage (puree processing, water storage in vestibule of restroom). 2) Dietary staff (B) failed to use good hygienic practices during dietary duties (transport of foods), 3) Food contact and non-food contact equipment was soiled (drink gun, exteriors of equipment). 4) Foods beyond the manufacturer's Use by dates were stored with in-use/current foods (honey thickened liquids). 5) The kitchen restroom was not fully enclosed. […]

• No harm, potential for more than minimal, patternF550Mar 20, 2025

  Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #12, Resident #81, and Resident #93) reviewed for rights. The facility failed to ensure CNA D and RA C knocked on Resident #12's, Resident #81's, and Resident #93's door when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #12's Face Sheet dated 03/19/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF880Mar 20, 2025

  Based on observations, interviews, and record review the facility failed to ensure the facility established and maintained an infection prevention program designed to provide a safe environment and to help prevent the transmission of communicable diseases for 3 of 5 staff (LVN A, MA B and Certified Nurse Aide D ) observed for infection control LVN A and MA B failed to disinfect the blood pressure cuff while using it on Residents #94, Residents #19 , Residents #39 , Residents #301. The facility failed to ensure Certified Nurse Aide D conducted hand hygiene in between feeding assistants of residents during dining. […]

• No harm, potential for more than minimal, patternF881Mar 20, 2025

  Based on interview and record review the facility failed to establish an infection and prevention and control program that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 3 of 8 residents (Residents #48, #52, and #95) reviewed for antibiotic stewardship program. The facility failed to follow the antibiotic stewardship policy for Residents #48, #52, and #95 by not ensuring an infection surveillance form was completed to ensure the appropriateness of the antibiotic per facility policy. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased multi drug resistant organisms. […]